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[Dr. Lizme Ajith]
Renal
calculi or renal stones consist of aggregates of crystals and small amounts of proteins
and glycoproteins. Different types of stones occur in different parts of the
world. Studies have shown that 4% of the total population has stones in the
urinary tract.
The
exact aetiology is unknown, the various predisposing factors may be
1)
Dietary factors:
Diet
rich in red meat, fish, eggs.
Diet
rich in calcium: milk, spinach, rhubarb etc produce calcium oxalate stones.
Diet
lacking in vitamin A causes desquamation of renal epithelium and the cells form
a nidus around which the stone is deposited.
2)
Renal infection: Organisms such as streptococci, staphylococci, proteus,
pseudomonas, klebsiella, E.coli produce recurrent urinary tract infection,
producing urea which causes stasis of urine precipitates
calcium formation.
3)
Metabolic causes:
a)
Hyperparathyroidism: increases the calcium levels resulting in hypercalcaemia
and hypercalciuria producing calcium stones.
b)
Gout: increases the uric acid levels and cause multiple uric acid stones.
4)
Prolonged immobilisation: from any cause, eg: paraplegia is liable to result in
skeletal decalcification with increase in urinary calcium favouring the
formation of calcium phosphate calculi.
5)
Inadequate urinary drainage: as in cases of horse shoe kidney, undescended
kidneys are more vulnerable for development of stones due to stasis.
6)
Altered urinary solutions and colloids: Dehydration leads to an increased
concentration of urinary solutes and tends to cause them to precipitate.
7)
Decreased urinary citrate: The presence of citrate in urine as citric acid,
tends to keep otherwise relatively insoluble calcium phosphate in solution.
When citrate level decreases, it precipitates the urinary
calcium.
8)
Hot climates: cause increase in concentration of solutes by excessive sweating
resulting in precipitation of calcium.
9)
Randall’s plaque: Randall suggested that initially a small erosion or an ulcer
develops on the tip of renal papilla on which minute concretions or minor
calcium particles or microlith get deposited and give
rise to stone formation.
Types
of renal calculus:
1.
Oxalate calculus (= Cacium oxalate)
The
commonest type of stone, called as mulberry calculi. Irregular in shape,
covered with sharp projections which tends to cause bleeding. Produces haematuria
very early, resulting in deposition of blood over the stone giving a dark
colour to it. Hard and single, occurs in infected urine. Can be visualized
radiologically.
2.
Phosphate calculi (= usually Calcium phosphate/rarely as Magnesium ammonium
phosphate = Struvite)
Smooth,
round, dirty white to yellow in colour. Commonly occurs in renal pelvis/tend to
grow in alkaline urine (proteus organisms present). As it enlarges in the
pelvis, it grows and
fills
the calyces and slowly forms a stag horn calculus. Produces recurrent urinary
infections and bleeding. As they are large, they are usually easy to see on
radiographs.
3.
Uric acid calculus
Multiple,
small, hexagonal, multifaceted. Colour varies from yellow to reddish brown.
Occur in acidic urine. Pure urate stones not visible radiologically unless
contaminated with calcium salts.
4.
Cysteine calculus
In
the urinary tract with a congenital error of metabolism that leads to
cystinuria or due to decreased resorption of cystine from renal tubules. They are
hexagonal, multiple, pink or yellow. Occur in acidic urine. Seen in young girls
at puberty. Not visible radiologically due to sulphur content.
5.
Xanthine calculus
Extremely
rare. They are smooth and round, brick red in colour and show lamellation on cross
section.
In
all cases the basic initiating factor is super saturation of urine which leads
to crystallization. The crystals get deposited on a nidus and when the
conditions are favourable, the stone grows.
50%
of patients present between the ages of 30 - 50 years. The male to female ratio
is 4: 3.
The
leading symptoms in 75% of people.
1)
Renal pain: posteriorly in the renal angle or anteriorly in the hypochondrium
in costal margin or in both. It may be worse on movement, particularly on
climbing stairs. It is described as fixed renal pain or
costovertebral pain.
2)
Ureteric colic: When the stone is impacted in the pelviureteric junction or
anywhere in the ureter, it results in severe colicky pain radiating from the
loin to the groin. It may also extend to the testicles,
vulva and medial side of thigh. This
may be associated with strangury, the painful passage of a few drops of urine,
with pallor, sweating and vomiting/groans in agony.
3)
Haematuria: common with oxalate stones. The quantity of blood lost is small,
but is fresh.
4)
Urinary tract infection: fever with chills and rigors, pyuria, burning
micturition and increased frequency of micturition may occur. In severe cases,
even septicaemia can quickly develop.
5)
Rigidity and guarding: abdominal examination during an attack reveals rigidity
of the lateral abdominal muscles and of the rectus abdominis. Percussion over
the kidney produces a stab of pain and there may
be tenderness on gentle deep palpation.
Complications:
1.
Calculous hydronephrosis: occurs due to back pressure producing renal
enlargement. Due to the stretching of the renal capsule, it results in pain in
the loin and an associated palpable kidney mass
suggests hydronephrosis.
2.
Calculous pyonephrosis: Kidney is converted into a bag of pus when
hydronephrosis becomes infected.
3.
Renal failure: Bilateral staghorn calculi may be asymptomatic until they
present with uraemia.
Investigiations
1)
Radiography: plain x-ray (KUB) helps to diagnose 90% of renal stones. It can be
visualized as an opacity which overlies the urinary tract and keeps a
relatively constant position during respiration. Enlarged renal shadow can also
be made out.
2)
Intravenous pyelography or excretora urography: This helps to locate the stone
exactly in relation to kidney and ureter and to assess renal function. A
radiolucent stone can be seen as a filling defect. Hydronephrosis can also be
made out.
3)
Ultrasonography: is the most valuable to diagnose the stone, its size and exact
location. It also confirms the enlarged kidney.
4)
Urine culture and sensitivity: Examination of urine for protein, R.B.C, W.B.C,
micro organisms reveals abnormalities of urinary tract, infection etc.
5)
Investigation of renal function: Blood examination for urea, creatinine, creatinine
clearance etc to rule out renal failure.
6)
Investigation to determine underlying causes: plasma calcium, phosphate,
parathormone, plasma urate, 24 hour urine urate, cystine and oxalate and
calcium.
7)
Stone analysis: analysis of any stone that has been passed.
Treatment:
Dietary
advice: drink plenty to keep their urine dilute. Fluid intake should be
therefore 3 litres per day, more if the climate or patient’s occupation causes
much sweating.
In
hypercalciuria: intake of milk, cheese and other dairy products should be
avoided.
In
oxalate stones: avoid spinach, rhubarb, strawberries, plums and asparagus.
In
hyperuricaemia: avoid redmeats, inards and fish rich in purines.
In
cystinuria:.Eggs, meat and fish are high in sulphur containing proteins and
should be restricted
Non
operative treatment:
-
Small stones less than 5 mm in size pass off with intake of copious amount of
fluids and at times forced diuresis. Intravenous hydration may help pass the
stones spontaneously.
-
extracorporeal shock wave lithotripsy: the calculus is bombarded with shock
waves of sufficient energy so that it will disintegrate into fragments using
lithotriptors. The fragments then pass down the ureter and are cleared out.
Operative
treatment:
Homeopathic
treatment:
Berb.: treatment: Renal colic < l.
Stitching, cutting pain from l. kidney following course of ureter into bladder
and urethra. Burning and soreness in region of kidneys. Pain in small of back,
SENsitive to touch in renal region < sitting/lying/from
jar/fatigue/motion/any sudden jarring movement/walking/riding in carriage.
Numbness,
stiffness and lameness with painful pressure in renal and lumbar regions.
Bubbling sensation in kidneys. Urine greenish, blood red, with thick, slimy
mucus, transparent, reddish or jelly like sediment. Rheumatic and gouty
complaints with urinary diseases.
Canth.:
Constant urging to urinate, passing but a few drops at a time, which is mixed
with blood. Intolerable urging before, during and after urination. Violent
paroxysms of cutting and burning in whole renal region. Violent tenesmus and
strangury. Urine scalds and passed drop by drop. Membranous scales looking like
bran in water. Urine jelly like, shredy. Pain raw, sore, burning in every part,
internally and externally. Over sensitiveness of all parts. Drinking even small
quantities of water increases pain in bladder.
Lyc.: Renal colic, r. Pain shooting
across lower abdomen from r. to l. Pain in back relieved by urinating. Urine
slow in coming, must strain. Retension. Polyuria during night. Red sand in
urine. Uric acid diathesis. Child cries before urinating. Pains drawing, aching
< 16 – 20 h. Upper part of the body emaciated, lower part semidropsical.
Ailments from fright, anger, mortification, reserved displeasure. Avaricious,
greedy, miserly, malicious, pussilanimous. Excessive accumulation of
flatulence, lower abdomen. > warm food and drinks.
Sars.:
Passage of small calculi or gravel, renal colic, stone in the bladder.
Excruciating pains from right kidney downwards. Severe almost unbearable pain
at conclusion of urination. Urine bloody, scanty, slimy, flaky, sandy, copious,
passed without sensation, deposits white sand. Painful distension and
tenderness in bladder, urine dribbles while sitting, passes freely when
standing. Air passes from urethra, child screams before and while passing
urine.
Tab.: Renal colic, violent spasmodic
pains along ureter, left side. With deathly nausea and vomiting. Vomiting
violent, with cold sweat, on least motion, with faintness > open air. Nausea
incessant as if seasick > in fresh cold air. Vertigo, death like pallor, on
opening the eyes. Face pale, blue, pinched, sunken, collapsed. Terrible, faint,
sinking feeling at the pit of stomach. Icy coldness of surfaces.
Nux-v.: Renal colic, r. Pain ext. r.
thigh and to the genitals. Frequent ineffectual urge for urination with
dribbling of urine. Haematuria, strangury. While urinating, itching in urethra
and pain in neck of bladder. Backache, must sit up or turn over in bed. Adapted
to thin, irritable, zealous, nervous, literary, studious, responsible persons.
Bad effects of coffee, tobacco, alcohol, highly spiced food, overeating, long
continued mental exertion. Over sensitiveness to all external impressions.
Frequent ineffectual urging for stool.
Oci-s.: Renal colic, r. Uric acid
diathesis. Red sand in urine. High acidity, formation of spike crystals of uric
acid. Turbid, thick, purulent, bloody, brick dust red or yellow sediment. Odour
of musk. Pain in ureters, cramps in kidneys.
Bell.: Violent spasmodic pains in kidney
region (r.). Pain comes suddenly, last indefinitely and cease suddenly. Pains
usually in short attacks. Redness of eyes and face, throbbing of brain and
carotids. Abdomen tender, distended, < least jar (of the bed)/slight
noise/light/lying down. > pressure/tight bandaging/wrapping up. Bilious
lymphatic plethoric constitutions.
Cham.: Insupportable pains in loins and
hips. Pains seem unendurable, drives to despair < heat/evening before
midnight/with heat/thirst and fainting with numbness of affected
parts/eructations. Violent pains, drive him out of bed, compels to walk about.
Over sensitive to pain, to open air. Cannot endure anyone near him, is
cross/irritable/easily angered.
Coloc.: Pain urinating over whole
abdomen. Vesical catarrh, discharge like fresh white of egg. Red hard crystals.
Renal colic < l. Agonising pain in abdomen causing patient to bend double, with
restlessness, twisting and turning to obtain relief. > hard pressure. Pains
< eating and drinking > warm application. Shooting pains like electric
shocks. Complaints from anger, indignation, mortification.
Dios.: Renal colic with pains radiating
to the extremities. Colic pains < bending forward/lying. > standing
erect/bending backwards. Violent twisting colic, occurring in regular paroxysms
„As if abdomen grasped and twisted by a powerful hand“. Pain suddenly shift to
different parts, appear in remote localities as fingers and toes.
Hydrangea.: Renal calculi, gravel, profuse deposit of white amorphous salts in
urine. Renal colic, sharp pain in loins, especially left. Burning in urethra
and frequent desire. Urine hard to start. Bloody urine, heavy deposit of mucus.
Great thirst with abdominal symptoms and enlarged prostate.
Pareir.: Renal colic, pain going down the
thighs. Neuralgic pain in the anterior crural region. Constant urging, great
straining. Can emit urine only when he goes on his knees, pressing head firmly
against floor. Black, bloody, thick mucus urine. Dribbling after micturition.
Urethritis, prostatitis.
Fab.: Excoriating urine and calculi.
Uric acid diathesis. A terebinthine diuretic. Vesical tenesmus and burning
after urination. Dysuria, cystitis, prostatitis, gonorrhea. Cholelithiasis and
liver affections.
Hedeoma.: Dull burning pain over left
kidney. Pain along left ureter. Dragging pain from kidney to bladder. Red sand
in urine. Frequent urging, cutting pains. Frequent intense desire to urinate
and inability to retain urine for more than few minutes, > urinating.
Epig.: Renal calculi, gravel, uric acid
deposits. Fine sand in urine of a brown colour. Dysuria, tenesmus after
urination. Burning in neck of bladder while urinating. Chronic cystitis,
mucopus, pyelitis, incontinence of urine.
Eryng-a.: Renal colic. Pain behind pubes.
Congestion of kidneys with dull pain in back, running down the ureters and
limbs. Difficult and frequent micturition. Strangury with nervous erethism.
Tenesmus of bladder and urethra. Thick yellow mucus discharges.
Eupat-pur.: Deep dull pain in kidneys.
Dysuria, haematuria, strangury. Boring in bladder and urethra on urinating.
Vesical irritability in women. Insufficient flow, milky. Albuminuria, dropsy,
diabetes, enlarged prostate.
Thlas.:
Renal colic. Accumulation of gravel. Brick dust sediment. Urine heavy,
phosphatic. Dysuria and spasmodic retension. Uric acid diathesis. Renal and
vesical irritation. Urethritis, urine runs away in little jets. Haematuria and
albuminuria.
Oxyd.:
Vesical calculi. Irritation at neck of bladder. Urine suppressed. Dropsy.
Deranged portal circulation. Prostatic enlargement.
Solid.: Urine scanty, reddish brown,
thick sediment, dysuria, gravel. Pain in kidneys extends forward to abdomen and
bladder. Urine difficult and scanty, albumen, blood and slime. Kidneys
sensitive to pressure. Backache of congested kidneys.
Pariet.:
Renal calculi. Night mares, patient dreams of being buried alive.
Stig.: Renal lithiasis, nephritic colic.
Blood and red sand in urine. Suppression and retension of urine. Dysuria,
tenesmus after urinating. Uric and phosphatic gonorrhea. Urinary symptoms
associated with organic heart disease.
Ipom.: Renal colic, aching in small of
back and extremities. Pain in left lumbar muscles on stooping. Aching in top of
right shoulder.
Vesi.: Smarting, burning sensation along
urethra and bladder with frequent desire to void urine often with strangury.
Cystitis, irritable bladder.
Xant.:
Severe pain in kidneys, cystitis and gravel. Pain from ureter to bladder and
testicles. Pain in small of back returns from least chill or damp.
Uva.: Calculous inflammation. Chronic
vesical irritation with pain, tenesmus and catarrhal discharges. Burning after
the discharge of slimy urine. Frequent urging with severe spasms of the
bladder. Urine contains blood, pus and much tenacious mucus, with clots in
large masses. Painful dysuria. Involuntary green urine. Cystitis with bloody
urine.
Coc-c.: Urinary calculi, urates and uric
acid. Brick red sediment. Haematuria. Deep coloured thick urine. Dysuria, urging
to urinate. Lancinating pains from kidneys to bladder. Chronic bronchitis
complicated with gravel.
Chinin-s.: Small amount of urea and
phosphoric acid with excess of uric acid and abundance of chlorides. Bloody
urine. Albuminuria. Chronic interstitial nephritis. Turbid, slimy, clay
coloured, greasy sediment. Complaints from suppressed malaria.
Benz-ac.: Excess of uric acid in urine. Urine
high coloured, urinous odour highly intensified. Dark brown, highly offensive.
Gonorrheal and syphilitic patients. Pain suddenly change their locality. Rheuma
and gout.
Nit-ac.: Cloudy phosphatic urine. Scanty,
dark, offensive, smells like horse’s urine. Urine bloody, albuminous, turbid,
looks like remains of cider barrel, cold on passing. Pricking splinter like
pains. Complaints after continued loss of sleep, over exertion of mind and
body.
Med.: Renal colic. Painful tenesmus
when urinating. Severe pain in renal region > by profuse urination. Intense
pain in ureters, with sensation of passing of calculus. Urine flows very
slowly. Ailments from suppressed gonorrhea. Women with chronic pelvic
disorders. < thinking of ailments/day time. > lying prone.
Sep.: Red adhesive sand in urine.
Chronic cystitis, slow micturition with bearing down sensation above pubes.
> by violent exercise, warm application. Involuntary urination during first
sleep. Urine highly offensive, must be removed from the room. Pains from other
parts to back, attended with shuddering. Sensation of ball in inner parts.
Weeps easily, indifference to those loved best.
Chima.: Urine loaded with ropy,
mucopurulent sediment. Urine turbid, offensive, scanty. Burning and scalding.
Must strain before flow comes. Unable to urinate without standing with feet
wide apart and body inclined forward. Prostatic enlargements.
Senec-a.: Renal colic, great heat and constant
urging. Nephritis. Scanty, high coloured, bloody with much mucus and tenesmus.
Irritable bladder with headache. Backache of congested kidneys. Functional
amenorrhea.
Cal-ren.: Gravel and renal calculi.
Piperazinum.:
Urinary calculi, uric acid diathesis. Constant backache. Urine scanty.
Rheumatic urethritis.
Polyg-s.: Pains of nephritic colic, lancinating
pain along spine. Suppurative nephritis. Aching pain in hips and loins.
Nit-m-ac.: Gravel. Oxaluria, almost a specific. Urine cloudy, burning in
urethra. < eating meat, alcohol.
Baros.: Gravel. Irritable bladder with
vesical catarrh. Mucopurulent
discharges.
Vorwort/Suchen Zeichen/Abkürzungen Impressum